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Designing residential environments for living better with dementia

Care providers need to move from a negative disabling approach to a more positive enabling mind-set that respecting residents as adults who have rich histories and can live meaningful lives. A ‘dementia friendly’ environment is argued to compensate for disability and should consider both the importance for the person with dementia of his/her experiences within the environment. Such environments aim at building on what people living with dementia, rather what they cannot do, allow them to experience the highest possible quality of life.  A literature on designing facilities for people with dementia, which has accumulated over the last 40 years, or so, provides support for the inclusion of a number of features into care homes that accommodate people with dementia. There is converging evidence that intelligent design of buildings, if regarded as a therapeutic resource, can promote well-being and functioning of people with dementia.

There has been increasing interest, overall, in the use of non-pharmacological interventions to improve dementia symptoms and the wellbeing of residents with dementia and their carers.  Previous studies examining modifications to the built environment have drawn from a number of design principles and frameworks for dementia care homes and suggest that purposeful design of one’s surroundings may play an active role in promoting a sense of well-being and improved functionality. The increased sensitivity of persons with dementia to environmental conditions occurs because the illness can reduce the individual’s ability to understand the implications of sensory experiences in residential care settings. As a result, agitated behaviours, increased confusion, delusions, and other psychiatric disturbances are readily triggered by environmental stimuli.

Inappropriate physical environment of the dining room is one of the most frequent concerns voiced by staff in nursing homes. Dining rooms are often loud and overstimulating places in care homes. In terms of physical environments, designs which provide balanced and controlled stimulation, and features that assist orientation, compensate for disability, and promote involvement in everyday activity are sought. With the aging population, research in home environments has developed a new focus of “environmental geriatrics” which includes professionals with backgrounds in anthropology, architecture, geography, occupational therapy, psychiatry, psychology, and other fields, as well as people living with dementia and caregivers. But dementia is not just about old people.

The focus of long-term care settings for the elderly has gradually changed from curing diseases to improving their quality of life, especially in countries which have been experiencing the aging of the population. In terms of the concept of care, the term “person-centered care” has already generated a lot of attention. Many terms (e.g., resident-centered care, individualised care, consumer-directed care, patient-centered care, self-directed care) share the same basic concepts and definitions. A person-centred approach is considered to emphasise residents’ unique personal preferences and needs in order to guide caregivers, thus enabling the individualisation of care plans and care routines to improve quality of life and compensate for their impairment. Person-centered dementia care requires shift in attitudes, behaviours, and systems replacing the traditional model of care that primarily focuses on the “tasks.” This is a best practice concept guiding efforts to improve residents’ quality of life in long-term care facilities. The care philosophy recognises that individuals have unique values, personal history, and personality.

Kitwood who advocated for the critical importance of personhood stressed the importance of taking a holistic perspective in relating to and caring with the person with dementia. For example, including a person with dementia in conversations at mealtimes would be considered as “positive person work”, as it contributes to recognising that person as a valued person. Dawn Brooker also illustrated Kitwood’s philosophy of person-centered care using a “VIPS” framework—“V” as valuing the individual as a full member of society, “I” as providing individualised approach, “P” as understanding the perspective of the person living with dementia, and “S” as providing a social environment that supports well-being of the person.

The environment needs to be able to support remaining ability rather than operate to diminish it, and to support the development and maintenance of relationships. The design of physical environments within residential aged care facilities (RACFs) can improve or worsen wellbeing in people with dementia irrespective of level of care from nursing staff. In Australia, the Building Quality for Residential Services Certification guides the building quality of RACFs in general, but this legislation does not offer any standards catered specifically to a person-centred dementia unit design. A groundbreaking assessment tool for the ward environment was developed in collaboration with NHS trusts participating in “The King’s Fund’s Enhancing the Healing Environment” (EHE) programme. Since then over 70 care organisations have been involved in field testing the tools. These tools have been informed by research evidence, best practice and over 300 survey responses from those who have used the tools in practice. Each of the sections draws on this evidence to develop a rationale for effecting change in care environments. This rationale also addresses, to some extent, the visuospatial experiences often associated with dementia. Making accommodations for the cognitive problems which people with dementia face is a fundamental aspect of overcoming disAbilities: for example the intelligent use of signage in care homes can make a tremendous difference. It’s also known, further, that intelligent use of colours and textures can enhance the lived experience of people living with dementia in residential care settings.

From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for. Care provided by family and friends in the community on the one hand saved costs of formal care but on the other hand cause informal care costs, which more than outweigh the savings (König et al., 2014). Innes, Kelly and Dincarslan (2011) have reported on a study to evaluate the reliability and validity of two tools: The Design Audit Tool and the Environmental Audit Tool developed to audit how dementia-friendly internal and external environments (specifically care homes) are for people with dementia. Analysis of the home reports identifies variation and variability in meeting “dementia-friendly principles” as specified by both tools. Areas of variability included wayfinding, the use of colour and contrast, access to outside spaces, individualisation of personal and communal spaces, lighting and opportunities to engage with the environment.

“Household model units” are often created from traditional ward type environments. They, for example, are distinguished by having approximately 16 residents, a functioning kitchen, their own front door entrance and a separation of the bedrooms from the main communal living rooms. There is a philosophy of facilitating “person-centred care”, as opposed to institutional routines, supported by a consistent team of care workers providing much of the unit management and decision making for each household. They encourage domestic style relationships between residents, staff and relatives.

On the other hand, the policy of “aging in place”, meaning the ability of individuals to remain in their home in the community, is a consistent wish and expectation of middle aged and older people. Home adaptations (environmental improvements, or in the disability legislation, reasonable adjustments) and assistive technology provision are an increasingly attractive means of helping older people to maintain their independence and enhancing their quality of life. There has been, frustratingly, little systematic research into the feasibility and cost of pursuing such a policy. The lack of definitive evidence of a link between the quality of the environment and the wellbeing of people with dementia living in that environment is somewhat surprising given the evidence that is available on the beneficial effects of specific environmental interventions. “Housing with care”, such as extra care and continuing care housing, is becoming a preferred alternative amongst commissioners of adult social care to care homes for people with dementia. Contemporary research suggests that many people with dementia can lead good quality lives in extra care housing, at least in the mild to moderate stages.

The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people living well with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

The physical environment is therefore now emerging as an important determinant of psychosocial and health outcomes for older persons with dementia of the Alzheimer type and other dementias. Among demented residents of long-term care facilities, environmental factors have been linked to agitation, intellectual deterioration, orientation, and even sleep patterns. With more people with dementia living in care homes in the UK than ever before, there is growing recognition that the design of such internal and external spaces should meet dementia friendly principles. The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

This field is promisingly now moving fast, giving some meat to the bones of ‘dementia friendly communities’.

 

 

References

Innes A, Kelly F, Dincarslan O. Care home design for people with dementia: What do people with dementia and their family carers value? Aging Ment Health. 2011 Jul 1;15(5):548-56. doi: 10.1080/13607863.2011.556601.

König HH, Leicht H, Brettschneider C, Bachmann C, Bickel H, Fuchs A, Jessen F, Köhler M, Luppa M, Mösch E, Pentzek M, Werle J, Weyerer S, Wiese B, Scherer M, Maier W, Riedel-Heller SG; AgeCoDe Study Group. The costs of dementia from the societal perspective: is care provided in the community really cheaper than nursing home care? J Am Med Dir Assoc. 2014 Feb;15(2):117-26. doi: 10.1016/j.jamda.2013.10.003. Epub 2013 Dec 8.

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